Health Outcomes and Cost-effectiveness of Monoclonal SARS-CoV-2 Antibodies as Pre-exposure Prophylaxis
Authors: Stephanie Popping, Brooke E. Nichols, Brent Appelman, Jason J. Biemond, Magda Vergouwe, Frits R. Rosendaal, Marc van der Valk, Godelieve J. de Bree, W. Joost Wiersinga, Emma Birnie, Michiel Schinkel, Matthijs R.A. Welkers, Hans L. Zaaijer, Frans J. Ittersum van, Maarten F. Schim van der Loeff, Marije K. Bomers, Marie José Kersten, Mette D. Hazenberg, Jarom Heijmans, E. Marleen Kemper, Mark G.J. de Boer, Renée A. Douma, Marcel van den Berge, Robert-Jan Hassing, Heidi S.M. Amerlaan, Marit G.A. van Vonderen, Janneke E. Stalenhoef, Robin Soetekouw, Frank van de Veerdonk, Marvin A.H. Berrevoets, Robbert J. van Alphen, Frits van Osch, Jiri F.P. Wagenaar, Rob J. van Marum, Astrid M.L. Oude Lashof, Cees van Nieuwkoop
Journal: JAMA Network Open (2023)

Importance Pre-exposure prophylaxis with neutralizing SARS-CoV-2 monoclonal antibodies (mAbs PrEP) prevents infection and reduces hospitalizations and the duration thereof for COVID-19 and death among high-risk individuals. However, reduced effectiveness due to a changing SARS-CoV-2 viral landscape and high drug prices remain substantial implementation barriers. Objective To assess the cost-effectiveness of mAbs PrEP as COVID-19 PrEP. Design, Setting, and Participants For this economic evaluation, a decision analytic model was developed and parameterized with health care outcome and utilization data from individuals with high risk for COVID-19. The SARS-CoV-2 infection probability, mAbs PrEP effectiveness, and drug pricing were varied. All costs were collected from a third-party payer perspective. Data were analyzed from September 2021 to December 2022. Main Outcomes and Measures Health care outcomes including new SARS-CoV-2 infections, hospitalization, and deaths. The cost per death averted and cost-effectiveness ratios using a threshold for prevention interventions of $22 000 or less per quality-adjusted life year (QALY) gained. Results The clinical cohort consisted of 636 individuals with COVID-19 (mean [SD] age 63 [18] years; 341 [54%] male). Most individuals were at high risk for severe COVID-19, including 137 (21%) with a body mass index of 30 or higher, 60 (9.4%) with hematological malignant neoplasm, 108 (17%) post-transplantation, and 152 (23.9%) who used immunosuppressive medication before COVID-19. Within the context of a high (18%) SARS-CoV-2 infection probability and low (25%) effectiveness the model calculated a short-term reduction of 42% ward admissions, 31% intensive care unit (ICU) admissions, and 34% deaths. Cost-saving scenarios were obtained with drug prices of $275 and 75% or higher effectiveness. With a 100% effectiveness mAbs PrEP can reduce ward admissions by 70%, ICU admissions by 97%, and deaths by 92%. Drug prices, however, need to reduce to $550 for cost-effectiveness ratios less than $22 000 per QALY gained per death averted and to $2200 for ratios between $22 000 and $88 000. Conclusions and Relevance In this study, use of mAbs PrEP for preventing SARS-CoV-2 infections was cost-saving at the beginning of an epidemic wave (high infection probability) with 75% or higher effectiveness and drug price of $275. These results are timely and relevant for decision-makers involved in mAbs PrEP implementation. When newer mAbs PrEP combinations become available, guidance on implementation should be formulated ensuring a fast rollout. Nevertheless, advocacy for mAbs PrEP use and critical discussion on drug prices are necessary to ensuring cost-effectiveness for different epidemic settings.